A nurse is caring for an infant who has returned to the pediatric unit following surgical repair of a cleft lip. Which of the following actions should the nurse take?
Monitor temporal artery temperature.
Restrain the infant's wrists.
Place the infant in a prone position.
Gently clean the suture line with povidone-iodine solution.
The Correct Answer is A
A. Monitor temporal artery temperature: Regularly checking the temporal artery temperature can help identify a fever early, allowing for prompt intervention if necessary.
B. Restrain the infant's wrists: Soft elbow restraints (not wrist restraints) are commonly used for infants post-cleft lip repair to prevent them from touching or rubbing the surgical site, which could disrupt the sutures and delay healing.
C. Place the infant in a prone position: After cleft lip surgery, infants should be positioned on their back to avoid pressure on the sutures and reduce the risk of injury.
D. Gently clean the suture line with povidone-iodine solution: It is typically recommended to clean the suture line with a sterile saline solution rather than povidone-iodine, which may irritate the site. Additionally, care should be taken to avoid disturbing the area too much.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Face, legs, activity, cry, consolability (FLACC) scale: The FLACC scale is appropriate for children aged 2 months to 7 years and assesses pain based on non-verbal cues such as facial expression, leg movement, activity, crying, and consolability.
B. Oucher scale and C. FACES scale are more appropriate for children aged 3 years and older who can self-report their pain.
D. Visual analog scale (VAS) is suitable for older children (typically 8 years and older) who can understand the concept of a continuum of pain.
Correct Answer is ["A","B"]
Explanation
A. Assess for changes in level of consciousness. Abdominal trauma can lead to internal bleeding, which might increase intracranial pressure if bleeding occurs in the brain. Monitoring for neurological changes is essential.
B. Administer factor VIII. Hemophilia A results from factor VIII deficiency, and replacing it prevents further bleeding.
C. Perform passive range of motion hourly. Movement may exacerbate bleeding into the joints or injured tissues. Rest is essential during acute bleeding episodes.
D. Administer factor IX. Factor IX is used for hemophilia B, not hemophilia A.
E. Apply a warming blanket over the child. Hypothermia management may be necessary in some trauma cases, but there is no indication it is needed here based on the scenario provided.
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